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Vertebroplasty / Kyphoplasty

Vertebroplasty
Vertebroplasty can be defined as “a procedure in which Bone Cement is injected into a vertebral body compression fracture”. This procedure can be performed percutaneously (through a small hole) with CT or under direct fluoroscopy, or as an open surgical procedure.

Kyphoplasty
In Kyphoplasty, a balloon is inserted into a fractured and compressed vertebra and inflated, after which acrylic cement is injected into the resulting cavity. Kyphoplasty is designed to relieve pain and improve spinal deformities associated with vertebral compression fractures

Main Indication:
To treat the pain caused by vertebral compression fractures from either Osteoporosis or tumor infiltration.
Spinal compression , most commonly caused by osteoporosis, are significant cause of morbidity and mortality in elderly population. Osteoporosis may be , age related (primary) or due to steroid use (sec).
Ideal candidates are patients who have failed conservative therapy and continue to have pain that negatively affects mobility activity of daily living. Patients with # of duration more than 6 weeks and less than 1 yrs.
One fourth of women over the age of 50 are affected by Osteoporotic bone fractures. Risk of fracture increases with age; women of 80 to 85 ages, up to 40% suffer Osteoporotic bone fracture.

Most Common Tumor Infiltrations
Osteolytic metastasis or multiple myeloma. Other pathological fractures include compression due to aggressive haemangiomas and giant cell tumors
Additional risk factors include : menopause, chronic steroid therapy, prolonged immobilization and renal insufficiency.
The pain caused by vertebral fractures may last for months and prove to be debilitating. Chronic pain, sleep loss, depression, decreased mobility and loss of independence are all sequel to vertebral compression fracture.

What levels?
Vertebroplasty up to T2, Kyphoplasty up to T5

Disadvantages Of Bed Rest
1 Bed rest accelerates bone loss
2 Increases risk of DVT
3 Muscle wasting which in combination with bone loss aggravates pain.
4 Decreased independence

GOAL
To bring about stability of the mechanically unstable vertebral bodies, thus relieving the pain.

PREOPERATIVE ASSESMENT
Your doctor will do a complete neurological examination- document any existing motor/sensory impairment
AP and Lat. Radiographs
CT to evaluate the post. Cortex for any disruption- risk of cement leakage into spinal canal during the procedure.
Bone scans
MRI - modality of choice, greater soft tissue resolution. Ability to differentiate acute and chronic #. Pain response is more closely related to severity of signal change on MRI, intense T2 signal band below the fracture, than the chronicity of the #.

WHERE TO DO?
Can be performed in OT/interventional radiology suit with biplanar imagining available, sterile surgical conditions and ability to immediately proceed with a Decompressive procedure in the event of cement extrusion into spinal canal.

TIMING OF OPERATIVE INTERVENSION
Argument in favor of early stabilization
  1. Minimization of subsequent deformity and its effect on appetite and breathing.
  2. Minimization of narcotic dependence and side effects.
  3. Immediate restoration of patient function and independence.

Non operative treatment- 3 to 6 weeks. Pts who have continuous pain after this interval can be considered for VBA.
Early intervention is suggested in pts:
Who are at significant risk of functional decline due to rest
Those patients who after several days of pain management therapy are still unable to ambulate.
Those who are unable to tolerate bracing or pain medication.
Serial collapse # on X-rays

ANAESTHESIA
Most Vertebroplasty and Kyphoplasty procedures are performed using only intravenous sedation (sent through an IV) and local anesthesia (shots that numb the area around the specific vertebra). In some instances, general anesthesia may be used.

  Collapse of D10            Vertebroplasty of D10 & prophylactic of D9 &11

KYPHOPLASTY
 Step 1          Fractured Vertebra
 Step 2          Insertion of Trochar
 Step 3 & 4    Inflation of Balloon
 Step 5          Removal of Balloon & Filling of Bone Cement
 Step 6          Vertebra with bone cement insitu.




Where you should not do Vertebroplasty
Your doctor may feel that the risks of these procedures are too great if you have:
• Vertebral fractures that extend into the posterior area of the vertebra, or a vertebral fragment that extends into the spinal canal area.
• Radiculopathy or irritation of a nerve root in the area of the fracture that often causes areas of numbness, tingling, or weakness in the leg.
• Fever
• Infection(bacteria in the bloodstream)
• Bone infection
• Bleeding disorders
• Unusually soft or porous bones

POSSIBLE COMPLICATIONS
• Leakage of the cement into the spinal canal or into adjacent veins
• Infection
• Bleeding
• Increased back pain
• Fracture of adjacent vertebra or ribs
• Numbness, tingling
• Paralysis

Average Hospital Stay
You will usually only need to stay in the hospital for a few hours on the day of the procedure, unless you have a complication that requires further monitoring, such as
• The need for intravenous anticoagulant medications (ie, blood thinning medication inserted through a vein)
• Fever
• New onset of numbness, tingling, or weakness
• Rib fracture
• Difficulty breathing

Postoperative Care
You may notice some discomfort at the site of the needle insertion or the tiny incision used for Kyphoplasty. This is often relieved through the use acetaminophen or nonsteroidal anti-inflammatory medications. You may also be given medications to prevent muscle spasm. You’ll be asked to stay in bed for about 24 hours after the procedure (with the exception of bathroom use). After 24 hours have passed, you can gradually increase your activities up to your usual level.

Outcome
Most people notice immediate and significant relief of their vertebral fracture pain after either Vertebroplasty or Kyphoplasty. Vertebroplasty has been very useful in treating pain associated with Osteoporotic comp. Fractures. In properly selected patients pain relief is up to 90 to 95%. This allows them to regain mobility, increase activity, and decrease the use of pain medication.
Call Your Doctor If Any of the Following Occurs
• Fever
• Bleeding
• New numbness, tingling, or weakness
• Severe pain in the ribs or other areas of your back
• Difficulty breathing

At Orthopedic`n`Spine Center Jalandhar, Vertebroplasty is being done regularly by Dr Sanjay Pal and patients are having good results and are pain free. Most of the patients who have undergone Vertebroplasty at our center are elderly with multiple medical problems with Osteoporotic fractures which have not become pain-free even after 4 to 6 weeks of bed rest.

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